Red State Hospitals Pressured To Care For The Poor Without More Medicaid

This is TELL ME MORE from NPR News. I'm Michel Martin. We're going to start the program today talking about health care. When the Affordable Care Act was created, it required every state to expand its government-funded Medicaid programs - that's the program that provides health insurance to low-income people - but a 2012 Supreme Court ruling declared that the federal government cannot require states to expand their Medicaid programs.

And about two dozen states have refused to do so. But those states still have to treat people who are too poor or not eligible for private insurance but don't qualify for Medicaid. And that issue is now coming to a head as states struggle to figure out how to balance their budgets without the additional federal money that would have come through Medicaid. We wanted to hear more about this so we've called two people who've been following the issue closely in their states. Jeffrey Hess is a reporter for Mississippi Public Broadcasting. He's been covering this issue in Mississippi. He joins us from the studios of Mississippi Public Broadcasting in Jackson. Jeffrey Hess, welcome.

JEFFREY HESS: Thank you for having me.

MARTIN: Also joining us, Becca Aaronson. She's a reporter for the Texas Tribune. And she reports on health care in Texas. And she's with us from Austin. Becca, welcome to you as well.

BECCA AARONSON: Thank you.

MARTIN: So, Jeffrey, let me start with you. Mississippi is one state that's refused government-funded Medicaid, as we mentioned. Why is that?

HESS: It's an ideological position. The conservatives who run the state here don't really trust the federal government, generally. They don't like Obamacare at all, specifically. And there's a lack of faith that the promises that the federal government's making, as far as how much money they're going to get for this care, is going to go away and then Mississippi is going to be left with an unaffordable burden of a huge Medicaid program where about 1 in 3 people in the state will be on the program.

MARTIN: So you're saying it's partly - it started with ideology and is also a fiscal issue - that they're worried that they'll have a mandate that they won't be able to pay for themselves.

HESS: And that's pretty much the dual running argument that the Republicans in the state make. And, naturally, all the Democrats here are in favor of expanding Medicaid. So it really is a Republican-Democrat issue here.

MARTIN: Becca Aaronson, what about you? Texas is another state that's refused or doesn't want to participate in this expansion of Medicaid. What's the reasoning there? Same?

AARONSON: Well, Governor Rick Perry has consistently said that putting more people on Medicaid would be like putting more people on the Titanic because he thinks the program is inherently broken and could sink our economy if we expanded it. So in addition to the, you know, questions of whether or not the federal government will be reliable in keeping its promise to fund 90 percent of the program, they also think that the program should be heavily reformed before they put any more people into it.

MARTIN: So, Jeff Hess, let's talk about who Medicaid would serve or who this expansion would serve, and what's the population of people who need to be served. And what's the status quo? How are they being served now? How are they getting their health care now?

HESS: Well, a lot of people it's you wait until it's an emergency and you go to the emergency room and likely don't pay. They're portrayed as the working poor. Mississippi has really restrictive current Medicaid eligibility so the people who would go in there are largely - they're food-service workers, they're cooks, they're people who are work in the construction industry, they're retail service workers. So for the most part it's people who are currently working and their job either doesn't provide health insurance or they can't afford it.

MARTIN: So how is this playing out - so, Jeff, stick with me for a minute here - how is this playing out? Now what's the concern about how this is going to work kind of going forward? I mean, the original idea was that if you brought these people into Medicaid, they wouldn't pose - they wouldn't wait until they were really sick and then go to the hospitals. So, presumably, they're still doing that. How is this playing out?

HESS: Well, the government's proposed a couple of different alternatives. There's a plan to give about $4 million to federally qualified health centers and rural health clinics to help them expand primary care. And the governor's also floated a proposal within the legislature to just straight up give hospitals money to offset the federal cuts that would have gone - or the federal support that is going way going forward. So that's two of the ideas that are out there right now.

MARTIN: Becca, what about you? Tell me what the situation is in Texas. So where - is it a similar population of people that we're talking about? And what are they doing for health care now? And what does the state envision to sort of address this?

AARONSON: Well, Texas has the highest rate of uninsured people in the nation. There's more than 6 million uninsured Texans. That translates to about $5 billion in uncompensated care costs every year for our hospital system. And so, as a result, hospitals are looking for a long-term solution if we're not going to expand Medicaid to care for these people. And currently, Texas has a waiver - a Medicaid waiver - from the federal government that's going to bring down $29 billion over five years. But a lot of that money is contingent on local hospitals and public hospital districts meeting benchmark standards set by the federal government to draw down the federal matching funds.

MARTIN: So what's going to happen?

AARONSON: It's hard to say what's going to happen exactly. But right now, we're in the middle of this transformation. And so a lot of these programs are going to work. And some of them could be models for the future, and some of them will fail. And so that's putting a lot of pressure on local county governments and public taxing districts so -because they have to front all the costs for these programs before they'll receive anything back from the federal government.

MARTIN: I mean, to that end, the idea of setting up an alternate model, I just want to play short clip from a conversation that I had earlier today with Anthony Keck. He's known as Tony Keck. He's the director of Health and Human Services for South Carolina Governor Nikki Haley. And this is what he told me. This is another state that's opted out of this Medicaid expansion. Here it is.

(SOUNDBITE OF ARCHIVAL RECORDING)

TONY KECK: The people who most need our help are sleeping under a bridge somewhere. But we don't go out and look for them because it's expensive and we frankly don't want them in our emergency rooms. Low-income people face a whole set of barriers to their health that go way beyond just the doctor's office visit. So what we're doing is actually focusing on finding the people most in need and getting them connected in a meaningful way to, not only a health care provider, but to other services in the community.

MARTIN: So, Becca, this kind of speaks to your point. I mean, part of his point of view here - his and presumably the governor's - is that, you know, Medicaid doesn't fix the problem, that it's still fee-for-service. It's like it's paying, you know, providers to treat people for a specific problem, but it doesn't kind of address the whole person or broader issues that may speak to health. And they feel they can do this more efficiently and in a way that speaks to the specific needs of the people who live there. And, Becca, that kind of tracks with something that you were talking about. Is there a similar idea here? Is this a similar kind of model that's being debated?

AARONSON: Yeah, I mean, Texas Republicans, they do want to fix our health care system. And one of the ideas they floated about fixing Medicaid it setting up cost sharing or personal responsibility measures or wellness incentives - things that will encourage people to stay healthy in order to access the health care services that they need. A lot of these waiver programs that the public hospitals are putting together include things like asking promotoras, women who can go into their Latina communities and talk to people about what will make them healthier, figure out what they need and create a dialogue of what will create healthy practices in their daily lives. And then also just expanding things like access to primary care in the clinic level so that people aren't going to hospital emergency rooms to seek basic assistance.

MARTIN: Yeah, it sounds as though there is a lot of discussion around different ideas going forward here. But is there a real kind of - how can I put this - a political discussion that tracks these ideas? I mean, is this - you both started talking about the fact that at the root of this is - you know, some of this, it's ideological, it's philosophical and it's political. And those three are often linked. And I just wondered whether the political players are having the same kinds of conversations around innovation and trying to address this problem, or is it mainly - is it really still a political back-and-forth? Jeffrey, do you want to start?

HESS: Oh, yeah. It's absolutely. I mean, in Mississippi specifically, you lose nothing by standing against Obamacare. It's only a gain if you're on the Republican side. But I think as we go forward even in this first year, we might see that begin to shift. A hospital recently laid off five doctors, and they said that Medicaid expansion was part of the reason. Some of our public support hospitals, my understanding is they're going to start going to their counties to ask for tax hikes to, you know, supplant what they would've gotten from Medicaid expansion. So I think when it becomes more real - a real issue instead of just, it's coming and we don't want to do it, then it'll change the politics.

MARTIN: I'm sorry, Jeff. Could you just explain that for me? You're saying that the doctors were laid off because of the Medicaid expansion or because the hospital couldn't receive the Medicaid funds or because they didn't participate participate in the Medicaid expansion? Is that why they were laid off?

HESS: The CEO of the hospital says in part they were laid off because the state did not expand Medicaid. And they're looking at the finances of it, and they're saying that we can't go forward without either the Medicaid expansion or some other massive influx of state money.

MARTIN: Becca, what about in Texas - similar debates going forward? And I just really want to hear more about, you know, how these conversations are playing out on the political side. You've told us a lot about kind of from a substantive, you know, perspective of how some of the ideas are going forward about how to address this. But what are the political conversations that people are having about this?

AARONSON: There's no doubt there's politics at play around Obamacare in Texas. We're in the middle of a primary season, and so it's very common for you to hear Obamacare bashing all around the state. But that said, there's also no denying the state denied $100 billion to our health care system. And so down at the grassroots level, that's going to equate to more taxes eventually on local taxing districts. And so once people start feeling the brunt of those cuts, they might feel differently about it.

Meanwhile, people are also being asked to purchase health insurance that might not have had to purchase it before, or they might have lost their plans that they previously lost. And so that's a factor on their minds more currently as how these changes are impacting them right away.

MARTIN: And speaking of that - and just - we have about a minute and a half left, and I just wanted to ask each of you, are these the kinds of conversations that citizens are having with each other? Is this a topic of public concern? I know that, you know, we're talking about it, news people talk about it, the political people talk about it, health people talk about it. But is this the kind of thing that people are talking about? Is this the kind of thing that surfaces a public concern? Jeffrey, you want to start?

HESS: Yeah, people talk to me about it because they know the industry that I'm in. But I don't think this is a real grassroots conversation among people who aren't really plugged in, and I think our state's exchange enrollment numbers bear that out. We're having the worst exchange enrollment of any state in the nation. So I think our low numbers there reflect the fact that people really aren't talking about it on their kitchen table level.

MARTIN: And, Becca, what about you? Final thought from you.

AARONSON: I think that I would agree with that. I mean, in Texas, people have been insured for a really long time. And if you've never had insurance, it's kind of hard to know where to even start. And the law is pretty confusing for a lot of people.

MARTIN: Becca Aaronson is a reporter for the Texas Tribune, with us from Austin. Jeffrey Hess is a reporter for Mississippi Public Broadcasting, with us from Jackson, Mississippi. Thank you both so much for joining us.